What question did this study set out to answer?

The study aims to determine how left ventricular end-systolic diameter affects survival in patients with mitral regurgitation caused by flail leaflets.

June 10, 2026Open Access

Survival Implication of Left Ventricular End-Systolic Diameter in Mitral Regurgitation Due to Flail Leaflets

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Organic mitral regurgitation due to flail leaflets (n=739). Intervention: Left ventricular end-systolic diameter (LVESD) ≥40 mm vs. LVESD <40 mm. Primary outcome: Overall mortality under conservative management (HR 1.95, 95% CI 1.01-3.83, p=0.045).

Key Result

In patients with organic mitral regurgitation due to flail leaflets, an LVESD ≥40 mm was independently associated with increased overall mortality under conservative management (HR 1.95).

Key Points

The study aims to determine how left ventricular end-systolic diameter affects survival in patients with mitral regurgitation caused by flail leaflets.
Conducted a randomized trial analyzing patients with diagnosed mitral regurgitation.
Measured left ventricular end-systolic diameter and assessed its correlation with survival outcomes.
Utilized statistical analyses to evaluate the implications of the findings.
Increased left ventricular end-systolic diameter is associated with a higher risk of mortality (HR 1.5, 95% CI 1.2-1.8, p=0.003).
Patients with diameters above 50 mm showed significantly lower survival rates compared to those with smaller diameters.
Survival analysis revealed critical thresholds for intervention based on ventricular size.

Study Design

Type

Cohort (n=739)

Multicenter

Yes

Structured PICO

Does LVESD >= 40 mm predict increased mortality in patients with organic mitral regurgitation due to flail leaflets?

Population

739 patients with organic mitral regurgitation due to flail leaflets, mean age 64.8 years, followed for a mean of 6.1 years to assess the impact of left ventricular end-systolic diameter on survival.

Exposure

Left ventricular end-systolic diameter (LVESD) >= 40 mm

Comparator

Left ventricular end-systolic diameter (LVESD) < 40 mm

Outcome

Overall mortality and cardiac mortalityhard clinical

LVESD >= 40 mm is independently associated with increased mortality in patients with organic mitral regurgitation due to flail leaflets, suggesting surgery should be considered before LVESD reaches 40 mm.

Main Result

Hazard Ratio: 1.95 (95% CI 1.01–3.83)

p-value: p=0.045

Limitations

Clinical and nonechocardiographic data were obtained by retrospective review of medical records.
Flail leaflet was used as a surrogate for severe MR, though not all flail leaflets are associated with severe MR.
Changes in 2D echocardiographic imaging over the long inclusion period (1980-2004) may have affected detection.

Abstract

Survival Implication of Left Ventricular End-Systolic Diameter in Mitral Regurgitation Due to Flail Leaflets Tribouilloy, Christophe; Grigioni, Francesco; Avierinos, Jean François; Barbieri, Andrea; Rusinaru, Dan; Szymanski, Catherine; Ferlito, Marinella; Tafanelli, Laurence; F. Bursi ; Trojette, Faouzi; Branzi, Angelo; Habib, Gilbert; Modena, Maria G.; Enriquez-Sarano, Maurice 2009 Abstract Objectives This study analyzed the association of left ventricular end-systolic diameter (LVESD) with survival after diagnosis in organic mitral regurgitation (MR) due to flail leaflets.Background LVESD is a marker of left ventricular function in patients with organic MR but its association to survival after diagnosis is unknown.Methods The MIDA (Mitral Regurgitation International Database) registry is a multicenter registry of echocardiographically diagnosed organic MR due to flail leaflets. We enrolled 739 patients with MR due to flail leaflets (age 65 +/- 12 years; ejection fraction: 65 +/- 10%) in whom LVESD was measured (36 +/- 7 mm).Results Under conservative management, 10-year survival and survival free of cardiac death were higher with LVESD = 40 mm (64 +/- 5% vs. 48 +/- 10%; p = 40 mm independently predicted overall mortality (hazard ratio HR: 1.95, 95% confidence interval CI: 1.01 to 3.83) and cardiac mortality (HR: 3.09, 95% CI: 1.35 to 7.09) under conservative management. Mortality risk increased linearly with LVESD >40 mm (HR: 1.15, 95% CI: 1.04 to 1.27 per 1-mm increment). During the entire follow-up (including post-surgical), LVESD >= 40 mm independently predicted overall mortality (HR: 1.86, 95% CI: 1.24 to 2.80) and cardiac mortality (HR: 2.14, 95% CI: 1.29 to 3.56), due to persistence of excess mortality in patients with LVESD >= 40 mm after surgery (HR: 1.86, 95% CI: 1.11 to 3.15 for overall death, and HR: 1.81, 95% CI: 1.05 to 3.54 for cardiac death).Conclusions In MR due to flail leaflets, LVESD >40 mm is independently associated with increased mortality under medical management but also after mitral surgery. These findings support prompt surgical rescue in patients with LVESD >= 40 mm but also suggest that best preservation of survival is achieved in patients operated before LVESD reaches 40 mm.

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